Entries in Riddle, Clive (271)

Friday
Aug252017

Fighting Over Who The Healthcare Punching Bag Should Be: Health Plans vs. Pharma

By Clive Riddle, August 25, 2017

Earlier this month the Doctor-Patient Rights Project released Not What the Doctor Ordered: Barriers to Healthcare Access for Patients an eighteen page report presenting consumer survey results regarding health insurance coverage denials. The Project issued statements in conjunction with the report including from Stacey Worthy, Executive Director of Aimed Alliance and one of the Project’s founding members, who said “our research reveals a hidden healthcare crisis. The current debate about healthcare reform has focused on getting more Americans covered. Yet, the real crisis is among patients with chronic illnesses who tell us that insurance is worthless when their insurance providers withhold coverage of essential treatments prescribed by a doctor.”

The Project highlighted that the survey found:

  • Insurance plans denied treatment coverage 24% of patients with a chronic or persistent illness or condition
  • 41% of these patients denied coverage were denied once, while 59% were denied multiple times.
  • 55% of those denied treatment said they were denied a prescription medication
  • 41% of those denied treatment said they were denied a diagnostic or screening test
  • 24% of those denied treatment said they were denied a medical procedure
  • 53% of those denied coverage for a treatment of a chronic or persistent illness appealed the denial
  • 49% of those appeals were ultimately successful
  • 70% of the denied treatments for chronic or persistent illnesses were for conditions described as “serious
  • 43% were for treatment of patients described as “in poor health”
  • 29% of patients initially denied coverage reported that their condition worsened
  • 34% denied coverage had to put off or forego treatment altogether

What isn’t clear at all in the report, is what the overall denial rate was for the 1,500 consumers surveyed. One wonders why that information wasn’t shared. The report focuses on denials for those responding that they had a chronic or persistent medical illness or condition, or on types of denials for the overall population surveyed.

The report tells us that 55% of the denials were for prescriptions, with 37% of these for formulary exclusions, while 12% required prior authorization, 9% required step therapy and 5% involved therapeutic substitutions. It becomes less clear from the report what portion of these denials still resulted in an alternative covered prescription, or ultimate coverage of the requested prescription after qualifying conditions were met.

The health insurance industry counters that runaway prescription costs are what we should be focusing on. The Blue Cross Blue Shield Association, AHIP and others have regularly produced reports highlighting the prescription cost problem. AHIP, for example one month ago posted Myth vs. Fact: What’s Behind Drug Prices on their website, in which AHIP goes about “fact-checking some of the pharmaceutical industry’s main arguments for why they have to charge hundreds of thousands of dollars for a course of treatment.” They cite reports and articles to support statements including: “High prices have little or nothing to do with drugs’ innovation or efficacy for patients”; “Pricing is based on what already exists, and competitors use shadow pricing to drive each other’s prices higher”; and “Instead of promoting true medical advances, a common business strategy in the pharmaceutical sector is to buy the rights to older drugs and then immediately jack up the prices.”

Morning Consult wrote about the dustup between the two sides this week, stating that health insurers are “alleging it [the Project Report] is part of a campaign by the pharmaceutical industry to distract the public from rising drug prices,” and that “Insurers say the coalition [Project] is tied to pharmaceutical companies.” The article quotes AHIP: “Big Pharma initiated another long-rumored political ad campaign in its attempts to distract from skyrocketing drug pricing, AHIP spokeswoman Cathryn Donaldson said in an email Monday, adding that instead of spending money on advertising campaigns, pharmaceutical companies should address high prescription drug prices.”

The article also quotes the other side punching back: “PhRMA spokeswoman Holly Campbell said pharma companies spend 20 percent of their revenue on research and development, fueling economic growth and bringing patients new treatments. In contrast, the insurance industry invested $0 in R&D and instead spend nearly 20 percent of premium dollars on administrative costs, she said in a Monday statement.”

Friday
Aug112017

Employer Surveys Project 2018 Cost Increases in the Five Percent Range

Employer Surveys Project 2018 Cost Increases in the Five Percent Range
 

by Clive Riddle, August 11, 2017

 

The National Business Group on Health has released results from their Large Employers’ 2018 Health Care Strategy and Plan Design Survey, which projects the total employer cost of providing medical and pharmacy benefits to rise 5% for the fifth consecutive year in 2018. The total cost of health care is estimated to be $13,482 per employee in 2017, and is projected to increase to $14,156 in 2018, with employers funding 70% of these costs. What is driving cost increases? The most often listed top driver was specialty pharmacy (26%) and 80% of employers ranked this among the top three cost drivers.

 

Similarly, last week Willis Towers Watson released preliminary findings from their 22nd annual Best Practices in Health Care Employer Survey, which found that "Employers expect health care costs to increase by 5.5%* in 2018, up from a 4.6% increase in 2017."

 

The NBGH 2018 survey also produced this grab-bag of interesting employer survey responses regarding health benefit strategies, regarding telehealth, onsite care, value based care, and CDHP:

 

·         96% will make telehealth services available in states where it is allowed next year

·         56% plan to offer telehealth for behavioral health services

·         20% of employers are experiencing employee telehealth utilization rates of 8% or higher

·         21%s plan to promote ACOs in 2018, and another 26% are considering offering them       

·         54% will offer onsite or near site health centers in 2018        

·         88% expect to use Centers of Excellence in 2018 for certain procedures        

·         40% of employers have incorporated some type of value-based benefit design

·         18% will use value-based benefit design to steer employees toward telehealth in 2018 (16% in 2017)

·         66% of companies will offer medical decision support and second opinion services in 2018

·         90% will offer at least one Consumer Directed Health Plan (CDHP) in 2018.

·         40% of employers will offer a CDHP as the only plan option in 2018, compared with 35% this year

·         28% pair a HDHP with a Health Reimbursement Arrangement
 

 
Friday
Aug042017

More on Medicaid Satisfaction: J.D. Power finds Medicaid Members More Satisfied Than Commercial Plan Members

More on Medicaid Satisfaction: J.D. Power finds Medicaid Members More Satisfied Than Commercial Plan Members
 

by Clive Riddle, August 4, 2017

Recently, we  posted about The July 10 , 2017 Research Letter published in JAMA, A National Survey of Medicaid Beneficiaries’ Expenses and Satisfaction With Health Care, which found that “Medicaid enrollees gave their overall health care an average rating of 7.9 on a 0 to 10 scale. Forty-six percent gave their Medicaid coverage a score of 9 or 10, while only 7.6% gave scores under 5.” We noted these relatively high satisfaction levels occur despite a study published in the May 2017 Health Affairs: Outpatient Office Wait Times And Quality Of Care For Medicaid Patients which found Medicaid patients were 20 percent more likely than others to wait 20 minutes or longer. We also noted Medicaid managed care satisfaction rates were also measured last summer, under a survey commissioned by AHIP, which found 87 percent were satisfied with their Medicaid coverage and benefits.

This week J.D. Power published a 2017 Managed Medicaid Special Report, which concludes that “Medicaid recipients are more satisfied with their coverage than traditional, commercial health plan members.” Their study measured “overall satisfaction with managed Medicaid organizations based on six factors (in order of importance): provider choice; coverage and benefits; customer service; cost; information and communication; and claims processing. Satisfaction is calculated on a 1,000-point scale.”

The study found that:

·           Overall managed Medicaid satisfaction averaged a 784 score

·           The Medicaid average score was 78 points higher than the commercial health plan score for 2017

·           Medicaid enrollees indicate provider choice as the most important factor of overall member experience

·           In contrast, commercial members list coverage and benefits as the key driver of satisfaction

·           42% of Medicaid managed care members deferred medical treatments due to cost

·           40% of Medicaid managed care members avoided buying prescription medications due to cost

Given that Medicaid is administered and differs at the state level, the study addressed state differences, and reports that “Medicaid recipients in states where a dominant regional plan or a plan that owns a health system have the easiest access to doctors and hospitals, underscoring the importance of building robust networks and focusing on coordination of care between providers. Iowa, Tennessee, Arizona and Indiana have the easiest access to doctors and hospitals, compared with the other states included in the study.”

The report also share that “the states with the highest levels of satisfaction among Medicaid recipients are Utah (885), Iowa (859), Colorado (854), Arizona (840) and Virginia (840). The lowest-performing states in terms of overall recipient satisfaction are Kansas (683), Mississippi (686), Delaware (716), New Jersey (728) and California (731).”

 
Friday
Jul212017

State Employee Benefit Plans Provide Insight Into Overall Group Benefit Trends

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By Clive Riddle, July 20, 2017

 

The Summer 2017 edition of Data, Segal Consulting’s publication providing research findings on public sector employee benefits, presents findings from their 2017 State Employee Health Benefits Study. As states are one of the largest employers, and their benefit decision making is directly impacted by policy makers, monitoring the pulse of state employee benefit plans provides insight into benefit trends for group coverage as a whole.

 

Andrew Sherman, Segal’s National Director of Public Sector Consulting, tells us “health benefits have become more important to state leaders as the cost of coverage outpaces overall inflation, placing budget pressure on health plan funding and underscoring the need for ongoing cost-management efforts. Examining what other states offer can be helpful for these leaders when they make difficult decisions about potential changes in coverage.”

 

The 23-page issue exclusively presents their study which involved a review of the websites for all 50 states and the District of Columbia in the fourth quarter of 2016, capturing medical, prescription drug, vision and dental plan information, as well as wellness and tobacco-cessation programs, including 105 PPOs/POS plans, 83 HDHPs/CDHPs, 149 HMOs/EPOs and five indemnity plans.

 

One insight from the study was “there are stark geographic discrepancies to where it is offered. According to the study, 13 Southern States offer HDHP/CDHPs, compared to just two in the Northeast. They are offered in eight states in the Midwest and seven in the West.” This equates to 22% of the states in the Northeast, 76% in the South, 67% in the Midwest and 54% in the West offering consumer driven plans.

 

Single premium increases averaged 8% for HMO/EPO plans, 10% for PPO/POS plans and 14% for HDHP/CDHP plans. The average single monthly premium was $780 for HMO/EPO plans, $713 for PPO/POS plans and $563 for HDHP/CDHP plans. Single deductibles averaged $194 for HMO/EPO plans, $483 for PPO/POS plans and $1,997 for HDHP/CDHP plans.

 

For the prescription benefit, single copayments averaged $9 for generic, $29 for brand formulary, $53 for brand non-formulary, and $101 for specialty drugs.

 
Thursday
Jul132017

Medicaid Patient Satisfaction: High Despite Naysayers and Longer Wait Times

Medicaid Patient Satisfaction: High Despite Naysayers and Longer Wait Times
 

By Clive Riddle, July 13, 2017

 

The July 10 , 2017 Research Letter published in JAMA, A National Survey of Medicaid Beneficiaries’ Expenses and Satisfaction With Health Care, and authored by researchers at the Harvard T.H. Chan School of Public Health frames the issue like this”: “some policymakers have argued that Medicaid is a broken program that provides enrollees with inadequate access to physicians. While numerous studies demonstrate that Medicaid increases access to care, the literature has less frequently focused on patient satisfaction among Medicaid enrollees themselves. We analyzed a newly released government survey examining Medicaid beneficiaries’ experiences in the program.”

Co-author Michael Barnett, assistant professor of health policy and management at Harvard Chan School, tells us “the debate on the future of Medicaid has largely marginalized a crucial voice: the perspective of enrollees. Our findings confirm that Medicaid programs are fulfilling their mission to provide access to necessary medical care.”

The authors used the Medicaid Consumer Assessment of Healthcare Providers and System (CAHPS) survey administered by CMS. Here’s their summary of results: “Medicaid enrollees gave their overall health care an average rating of 7.9 on a 0 to 10 scale. Forty-six percent gave their Medicaid coverage a score of 9 or 10, while only 7.6% gave scores under 5. Ratings were similar in Medicaid expansion and nonexpansion states (7.8 vs 7.9; P = .54). Ratings were slightly higher for older adults and dual-eligible beneficiaries, but similar in the fee-for-service and managed-care groups. Overall, ratings ranged from 7.6 to 8.3 across all demographic groups.”

Access was also addressed:  physician access, 84% of enrollees reported that they had been able to get all the care that they or their physician believed was necessary in the past 6 months, and 83% reported having a usual source of care. The mean percentage of beneficiaries able to get all needed care was significantly higher in Medicaid expansion states than in nonexpansion states (85.2% vs 81.5%; P < .001). Overall, only 3% of enrollees reported not being able to get care because of waiting times or physicians not accepting their insurance. Two percent reported lacking a usual source of care because 'no doctors take my insurance.'

This level of patient satisfaction comes despite a study published in the May 2017 Health Affairs: Outpatient Office Wait Times And Quality Of Care For Medicaid Patients which found Medicaid patients were 20 percent more likely than others to wait 20 minutes or longer, with the median Medicaid wait time for Medicaid patients 4.6 minutes past their scheduled appointment time, compared to 4,1 minutes for the privately insured. 18 percent of visits for Medicaid patients has a wait time of more than 20 minutes, compared to 16.3 percent for privately insured patients.

The concern stated with the study is the wait time would impact the Medicaid satisfaction rates measured in the CMS Consumer Assessment of Healthcare Providers and System (CAHPS). Yet the new survey findings would indicate otherwise.

Medicaid satisfaction rates were also measured last summer, under a survey commissioned by AHIP, which found:

·         87 percent were satisfied with their Medicaid coverage and benefits

·         Medicaid managed care plan member had higher satisfaction with their benefits (85 percent) in comparison to those enrolled in traditional Medicaid fee-for-service programs (81 percent);

·         9 percent) said they are dissatisfied with their coverage; and

·         83 percent were highly satisfied with their level of access to doctors when needed.